Care One At Lowell
19 Varnum Street, Lowell, MA 01850 · For profit - Limited Liability company · 160 certified beds · (978) 454-5644 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.5% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.8% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.0% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.9% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 4.0% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 46.5% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.4% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.0% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 45.9% | 21.4% | 17.1% | worse |
| Short-stay residents rehospitalized after admission | 31.7% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.2% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.00 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.72 | 1.50 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.2–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 160 beds and averages 152.0 residents a day — about 95% occupied, or roughly 8 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 3.81 on weekdays — 12% thinner on weekends. RN hours go from 0.30 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 21% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2023-04-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to prevent a decline in range of motion for 1 Resident (#63) out of a total sample of 37 residents. Findings include: Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. On 4/4/23 at 10:10 A.M., Resident #63 was observed lying in bed. His/her right knee was fully flexed (bent), with the Resident's heel touching his/her left upper, inner thigh. Resident #63 was unable to follow commands to straighten his/her leg and is not able to be interviewed. During an interview on 4/05/23 at 9:07 A.M., Nurse #1 said Resident #63's right knee has been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-21 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure physician visits were completed timely, completed as required for new admissions, and were alternated between the physician and the nurse practitioner for seven Residents (#26, #27, #144, #8, #129, #120 and #89) out of a total of 34 sampled residents. Specifically: 1. For Residents #26, #27 and #144, the facility failed to ensure they were seen by the physician as required after admission to the facility. 2. For Residents #8, #89, #120 and #129, the facility failed to ensure they were seen by the physician as required. Findings include: Review of Physician Visits policy, dated 2001 indicated: Policy Statement: The attending physician must make visits in accordance with applicable state and federal regulations. 1. The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-21 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to accurately document in the medical record for one Resident (#11) out of 34 total sampled residents. Specifically, for Resident #11, the nurses inaccurately documented insulin was administered when it was not. Findings include: Review of the facility policy titled 'Charting and Documentation', revised July 2017, indicated: - Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Resident #11 was admitted to the facility in July 2018 with diagnoses including diabetes, stage four chronic kidney disease, and congestive heart failure. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/18/25, indicated Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #11 received insulin daily. During an interview on 5/21/25 at 8:41 A.M., Resident #11 said his/her blood sugars are unstable and his/her insulin needs to be held if his/her blood sugar is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure a safe and homelike environment for one Resident (#133), out of 34 total sampled residents. Specifically, the facility failed to ensure Resident #133's sink was not leaking and good repair. Findings include: Review of the facility policy titled 'Homelike Environment', revised February 2021, indicated: - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Resident #133 was admitted to the facility in February 2024 with diagnoses including epilepsy (seizure disorder) and a history of a heart attack. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/4/25, indicated Resident #133 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 5/20/25 at 7:05 A.M., Resident #133 said his/her sink had been leaking for approximately two months. The surveyor and Resident #133 observed his/her bathroom sink which was actively dripping water into a plastic basin on the floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#115), when he/she was discharged from hospice services, out of a total sample of 34 residents. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2024, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. Resident #115 was admitted to the facility in January 2024 with diagnoses including Huntington's disease (an inherited condition that affects movement, thinking, and mood) and hypertension (high blood pressure). Review of the most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated Resident #115 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS also indicated Resident #115 was receiving hospice services. Review of Resident #115's nursing progress notes, dated 4/30/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-21 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#140) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled residents. Specifically, the facility failed to ensure nursing changed the water flush bag (a bag containing water that is connected to and delivers water for hydration through a gastrostomy tube) every 24 hours as necessary to prevent infection and maintain the integrity of the feeding system. Findings include: Review of the facility policy titled 'Enteral Nutrition Feedings (tube feeding), revised 7/26/13, indicated: - An open system (bag and tubing) may hang up to 24 hours unless compromised. Resident #140 was admitted to the facility in June 2024 with diagnoses including diabetes and sepsis. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/11/25, indicated Resident #140 was rarely/never understood and had severe cognitive impairment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#125) out of sample of 34 residents. Specifically, for Resident #125, the facility failed to provide oxygen to the Resident as indicated in the physician's orders. Findings include: Review of facility policy, titled Oxygen Administration, dated as revised October 2010, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders for facility protocol for oxygen administration. -Steps in the procedure: 9. Place appropriate oxygen device on the resident (i.e. mask, nasal cannula and/or nasal catheter). Resident #125 was admitted to the facility in July 2023 with diagnoses that included Chronic Diastolic Heart Failure, primary pulmonary hypertension and sleep apnea. Review of Resident #125's most recent Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-21 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews for two Residents (#62 and #126) out of five residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, 1.) For Resident #62, the nurse administered the incorrect dose of atorvastatin calcium (a medicine used to treat high cholesterol). 2.) For Resident #126, the nurse failed to ensure an order for aspirin included a dosage prior to administration. Findings include: Review of the facility policy titled 'Administering Medications', revised April 2019, indicated: - Medications are administered in accordance with prescriber orders. - The individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1.) Resident #62 was admitted to the facility in April 2019 with diagnoses including hypertension…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0779 — isolatedKeep signed and dated reports of x-rays and other diagnostic services in the residents record.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure diagnostic test results were maintained in the clinical record for one Resident (#120) out of a total of 34 sampled residents. Specifically, the facility failed to ensure the results of an ultrasound were reviewed and reported to the attending physician and filed in his/her clinical record. Findings include: Review of the Lab and Diagnostic Test Results Clinical Protocol policy dated November 2018 indicated: - When test results are reported to the facility, a nurse will first review the results. -A physician can be notified by phone, fax, voicemail, e-mail, pager or a telephone message. -Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report. Resident #120 was admitted to the facility in January 2024 with diagnoses including traumatic subdural hemorrhage immobility syndrome…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled Employee Personnel Records (Certified Nurse Aide #1), the Facility failed to ensure they conducted a Massachusetts Nurse Aide Registry background check before hire, in accordance with the Facility Policy. Findings include: Review of the Facility's Policy titled Background Screening Investigations, dated March 2019, indicated background checks are completed prior to employment. The Policy indicated that any employee applying for a position as a Certified Nurse Assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. Review of Certified Nurse Aide (CNA) #1's Personnel File indicated he was hired on 06/07/22. Further review of the file indicated there was no documentation to support that CNA #1 had a Massachusetts Nurse Aide Registry background check conducted by the Facility before hire. During an interview on 07/09/24 at 3:30 P.M., the Administrator, Director of Nurses (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to monitor and assess the use of equipment being used as a potential restraint for one Resident (#57) out of a total sample of 31 residents. Specifically, the facility staff failed to: For Resident #57, conduct individualized monitoring and ongoing assessments for the use of thigh bands (used to secure the body in a wheelchair to prevent sliding down in the chair and designed to relieve pressure on certain body areas) while lying flat. Findings include: Review of the facility policy titled Restraints: Physical, dated revised 10/13/2017, indicated that the purpose of the policy is to ensure that if a restraint is indicated to treat medical symptoms that it is the least restrictive device possible, used for the least amount of time possible in order to treat the medical symptoms. Resident #57 was admitted to the facility in October 2018 with diagnoses including Huntington's disease, psychosis and depression. Review of the Minimum Data Set assessment, dated 4/9/24, indicated that Resident #57 was not able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2024-06-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to develop a comprehensive plan of care for one Resident (#132) out of a total sample of 31 residents. Specifically, the facility failed to develop an individualized plan of care for Resident #132 related to migraine headaches. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated and revised 4/25/22, indicated the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Resident #132 was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow professional standards of practice for two Residents (#150 and #151) out of two closed records reviewed. Specifically, 1. For Resident #150, the facility failed to obtain a doctor's order for a transfer to the hospital and 2. For Resident #151, the facility failed to obtain a doctor's order for a transfer home. Findings include: The facility policy titled Transfer or Discharge, Facility-Initiated, dated 2001, failed to indicate that a doctor's order would be obtained for resident discharges. 1. For Resident #150 the facility failed to obtain a doctor's order for a transfer to the hospital. Resident #150 was admitted to the facility in June 2023 with diagnoses including Huntington's disease, schizophrenia and depression. Review of the progress note, dated 4/4/24, indicated that Resident #150 was transferred to the hospital on 4/4/24 via ambulance. Review of the doctor's orders, dated April 2024, failed to indicate an order to transfer Resident #150 to the hospital. During an interview on 6/25/24 at 4:05 P.M., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to conduct an assessment for trauma per the facility policy, and develop an individualized comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two Residents (#146 and #123) who had an active diagnosis of PTSD out of a total sample of 31 Residents. Findings include: 1. For Resident #146 the facility failed to conduct an assessment for trauma per the facility policy, and develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization. Resident #146 was admitted to the facility in March 2024 with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview, the facility failed to provide dental services for one Resident (#132) out of a total sample of 31 residents. Specifically: For Resident #132, the facility failed to ensure dental services were provided after it was reported that Resident #132 had dental pain. Findings include: Review of the facility policy titled Dental Services, revised and dated December 2016, indicated the following: - Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. - Routine and 24-emergency dental services are provided to our residents through a contract agreement with a licensed dentist comes to the facility monthly. - Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. Resident #132 was admitted to the facility in January 2024 with diagnoses including focal traumatic brain injury, major depressive disorder and epilepsy.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to ensure that housekeeping staff maintained proper hand hygiene practices on one of four nursing units. Findings include: Review of facility policy titled Handwashing/Hand Hygiene, dated as revised 3/18/24, indicated the following: - The facility considers hand hygiene the primary means to prevent the spread of healthcare- associated infections. - 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. - Indications for Hand Hygiene. 1. Hand hygiene is indicated. c. after contact with blood, body fluids or contaminated surfaces. e. after touching a resident's environment. g. immediately after glove removal. 5. The use of gloves does not replace hand hygiene/ hand washing. Review of facility policy titled Personal Protective Equipment- Gloves, dated July 2009, indicated the following: 2. Gloves shall be used only once and discarded…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Medical Orders for Life Sustaining Treatment (MOLST) were accurate for 1 Resident (#3), out of a total 37 sampled residents. For Resident #3, the facility failed to address the advance directives on the MOLST in the plan of care. Findings include: Review of facility policy titled Advanced Directives revision date, 9/2022 indicated the following: -Advanced directives are honored in accordance with state law and facility policy. -The plan of care for each resident is consistent with his or her documented treatment preferences and/or advanced directives. Resident #3 was admitted to the facility in February 2022, with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 was a Do Not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews, the facility failed to meet professional standards of practice during a medication pass with 1 Resident (# 34) out of 3 residents observed. Findings include: Review of facility policy titled ' Medication Administration' edited 5/21/19 indicated the following: Policy Interpretation and Implementation *27. Residents may self administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision making capacity to do so safely. On 4/5/23 at 8:09 A.M., the surveyor observed a medication pass on the Forthill resident care unit. Nurse #4 prepared and administered medications including the following: *Buspirone 10 mg (milligram) 2 tablets *Seroquel 25 mg 1 tablet *Notryptylin 25 mg 4 capsules (100 mg) *Pantoprazole dr (delayed release) 40 mg 1 tablet *Montelukast 10 mg 1 tablet *Strattera 40 mg 1 capsule *Effexor er(extended release) 150 mg 2 capsules *Cetrizine 10 mg 1 tablet *Folic acid 1000 mcg (microgram) 1 tablet *Flonase 50 mcg 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADL) for 1 Resident (#148) out of a total sample of 37 residents. Findings include: Resident #148 was admitted to the facility in February 2023 with diagnoses including diabetes. Review of Resident #148's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicates Resident #148 is dependent on staff for bathing tasks. On 4/4/23 at 8:12 A.M., Resident #148 was observed in his/her reclining chair in the hallway. The Resident had significantly greasy hair with white flakes similar to dandruff throughout the head. The Resident said he/she has not had a shower since admitting to the facility and would like one so his/her hair can be washed. Review of the shower schedule indicated Resident #148 is scheduled for showers on Mondays and Thursdays…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to follow recommendations of the optometrist for 2 Residents (#63 and #120) out of a total sample of 37 residents. Findings include: 1. Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. Resident #63 is not able to be interviewed. Review of an eye consult from 2/2/22, indicated the Optometrist made the following recommendation: *Artificial Tears Solution, apply 1 drop, Both eyes, three times daily for indefinitely. Review of an eye consult from 6/6/22, indicated the Optometrist made the following recommendation: *New Medication Order:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff provided appropriate care and services for one Resident (#3) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 37 sampled Residents. Specifically, the facility failed to follow physician orders for accurate water flush amount. Resident #3 was admitted to the facility in February 2022 with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 required tube feedings while a Resident. During an observation on 4/5/23 at 11:48 A.M., Resident #3's tube feeding pump was programmed to receive a water flush of 150 milliliters (MLS) every 4 hours.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, the facility failed to ensure that 1 Resident (#63), was seen by a physician every 90 days out of a total sample of 37 residents. Findings include: Resident #63 was admitted to the facility in January 2017 with diagnoses including dementia and Human Immunodeficiency Virus disease. Review of Resident #63's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident was unable to complete the Brief Interview for Mental Status exam and staff has assessed him/her to have severe cognitive impairment. The MDS also indicates Resident #63 is dependent on staff for all activities of daily living. Review of Resident #63's medical chart indicated he/she was seen by the nurse practitioner on 2/24/23 and 3/31/23. The medical chart failed to include any notes from the physician to indicate the Resident was seen by the physician in the last 90 days. During an interview on 4/6/23 at 1:09 P.M., the Director of Nursing (DON) said all residents in the facility need to be seen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. One nurse out of two nurses observed made 3 errors in 28 opportunities resulting in a medication error rate of 10.71%. These errors impacted 2 Residents (#111 and #22) out of 3 residents observed. Findings include: Review of facility policy titled 'Administering Medications' edited 5/19/21, indicated the following: Policy Statement: Medications are administered in a safe and timely and as prescribed. Policy Interpretation and Implementation *10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 4/5/23 at 7:28 A.M., the surveyor observed a medication pass on the Shed park resident care unit. Nurse #3 prepared and administered medications including the following to Resident #22: *chlorpromazine 50 mg (milligram) 3 tablets *diazepam 2 mg 2 tablets *colace 100 mg 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide dental services to 1 Resident (#120) out of a total sample of 37 residents. Findings include: Resident #120 was admitted to the facility in July 2019 with diagnoses including stroke and schizoaffective disorder. Review of Resident #120's most recent Minimum Data Set (MDS), dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #120 is independent with all daily self-care and mobility tasks. During interviews on 4/4/23 at 8:58 A.M., and 4/6/23 at 8:50 A.M., Resident #120 was observed with significant brown discoloration to his/her teeth. Resident #120 said he/she would like to be seen by the dentist to have a cleaning. Review of Resident #120's medical record indicated he/she was seen by the dentist on 1/23/22 with a recommendation to have annual exams. The record failed to indicate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff maintained medical records that were accurate for one Resident (#3) out of a total sample of 37 residents. Specifically, the facility documented that the incorrect enteral flush order was administered. Resident #3 was admitted to the facility in February 2022 with diagnoses including severe protein calorie malnutrition, dysphagia, and muscle weakness. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 4 out of a possible 15 indicating severe cognitive impact. Further review indicated Resident #3 required tube feedings while a Resident. During observations on 4/5/23 at 11:48 A.M., 4/5/23 at 11:48 A.M., 3:11 P.M. and 4:56 P.M., Resident #3's tube feeding pump was programmed to receive a water flush of 150 milliliters (MLS) every 4 hours. Review of Resident #3's medical record indicated the following: -Order date 4/3/23 with a start date of 4/4/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-05-21 · tag F0628 — widespreadProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold upon hospitalizations for three Residents (#129, #144 and #93) out of a total of 34 sampled residents. Findings include: 1. Resident #129 was admitted to the facility in January 2024 with diagnoses including paraplegia and communicating hydrocephalus. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #129 is cognitively intact evidenced by a score of 15 out of a possible 15 in the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #129 is totally dependent on staff for eating, bathing and mobility. Review of the clinical record indicated Resident #129 was transferred to the hospital on 1/18/25, 2/8/25, 3/4/25, 3/18/25 and 4/16/25. The clinical record failed to indicate if a transfer notice or bed hold notice was provided. During an interview on 5/20/25 at 1:37 P.M., the Social Worker said that the notices were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-06-27 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one Resident (#71) out of a total sample of 31 residents. Specifically, the facility coded Resident #71 as using a trunk restraint when he/she did not use one. Findings include: Resident #71 was admitted to the facility in January 2019 with diagnoses including traumatic subarachnoid hemorrhage and unspecified dementia. Review of Resident #71's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15 indicating that he/she is cognitively intact. Further review of section P of Resident #71's MDS indicated that the Resident used a trunk restraint less than daily. Review of section GG of Resident #71's MDS indicated he/she does not use any mobility devices and can ambulate independently. On 6/25/24, 6/26/24 and 6/27/24, the surveyor observed Resident #71 walking around the second-floor unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CAREONE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 36 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THCI OF MASSACHUSETTS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2003 |
| CARE REALTY, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/30/2002 |
| DES-I 2016 GRAT | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2021 |
| STRAUS, DANIEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2003 |
| BARUCH, DAVID | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 12/01/2021 |
| HEALTHBRIDGE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2003 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 95% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225224. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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